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Topical Corticosteroids PDF
Topical Corticosteroids PDF
Topical Corticosteroids PDF
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Navin Kumar Devaraj, MMed1, Aneesa Abdul Rashid, MMed1, Abdul Hadi Abdul Manap, MMed1, Shaaira Nasir,
MRCP2
1
Department of Family Medicine, Faculty of Medicine, Universiti Putra Malaysia, Serdang, Selangor, Malaysia, 2Department of
Dermatology, Homerton University Hospital Foundation Trust, Homerton Row, London, United Kingdom
SUMMARY
Topical corticosteroids are common medications prescribed
Generally, the use of topical corticosteroids should not be
INTRODUCTION
This include coming down the ladder to a less potent
corticosteroid once the skin inflammation and pruritus
Many skin conditions are treated with topical corticosteroids. improves, or going up the ladder for ineffective response with
This includes eczema, psoriasis, lichen sclerosus, lichen a weaker corticosteroid, albeit for a maximum of two weeks
planus, nodular prurigo, discoid lupus erythematosus and duration before reviewing. There is also a need to be cautious
vitiligo; to name a few.1-3 There are variety of factors to about the correct potency corticosteroids that are prescribed,
consider when choosing a topical corticosteroid including the e.g., hydrocortisone acetate 1% is safe for use over the face or
correct potency based on severity of clinical presentation, age in children but not hydrocortisone butyrate 0.1%.
group of patients, parts of the body affected, and the balance
between benefits versus side effects. Most corticosteroid preparation will recommend a daily or
twice-daily application dose, with no further improvements
More importantly, is the need for accurate clinical diagnosis noted with more frequent applications.4 To ensure that the
to ensure the correct use for the indication of topical appropriate amount of corticosteroid is applied, the usage of
corticosteroid and the need to exclude primary or secondary fingertip unit method is recommended, which is defined as
skin infection prior to prescription. Microscopic examination the amount squeezed from fingertip to the first crease of the
of skin scraping with potassium hydroxide can help in finger.4
identifying superficial fungal skin infection as the condition
may be worsened by the use of topical corticosteroid.4 As skin Table II shows the number of fingertip units needed to for
conditions comprise of one fifth of the cases seen in primary different regions of the body.4 For example, the palm of a
care, this article will offer guidelines to readers on the proper hand will require 0.5 fingertip units or 0.25g of
choice of corticosteroid for dermatological conditions corticosteroids.4 This will help physicians in dispensing the
commonly seen by clinicians.5 right amount of topical corticosteroids.
CHOOSING THE RIGHT POTENCY BALANCING BETWEEN BENEFITS AND SIDE EFFECTS OF
Topical corticosteroids come in either ointment (for dry or USING TOPICAL CORTICOSTEROIDS
scaly lesions) and lotion or cream formulation for wet lesions; Obvious benefits can be derived from topical corticosteroids if
with the ointment formulation having the highest potency. used in the correct potencies for the right indications. It can
The potency of steroids is increased if occlusive dressing is bring dramatic recovery to inflammatory dermatoses thereby
used, especially in a hydrated area of the body, damaged skin bringing relief to patients. However, there exists many side
or in flexures such as axilla or groin. Skin absorption of effects in the use of topical corticosteroids especially with
topical corticosteroid varies greatly with the variation in skin inappropriate and prolonged use. This includes:9,10
thickness at different body regions. Very thick skin at palms
and soles necessitates the use of potent topical corticosteroid 1. Systemic effects (especially with high or ultra-high
due to reduced absorption. Conversely, increased absorption potency formulation for prolonged duration of therapy)
in very thin skin at eyelids, face and genitalia leads to high a) Endocrine – Iatrogenic Cushing’s syndrome,
risk of adverse effects when even mild to moderately potent Hypothalamic-pituitary-adrenal suppression
topical corticosteroid is used at these areas for prolonged b) Metabolic- Aseptic necrosis of femoral head,
period.4 Table I highlights the potencies of various topical hyperglycaemia, short stature in children
corticosteroids, indications for use and areas to avoid.6-8
This article was accepted: 28 February 2019
Corresponding Author: Dr Navin Kumar Devaraj
Email: knavin59@yahoo.com
Table I: Potencies, main indications and areas to avoid use of various topical corticosteroids
Potency Examples (Strength Main Indications Areas To Avoid
Of Corticosteroids)
Ultra Highly Clobetasol propionate cream (0.05%) - Relief of the severe inflammatory Face, axilla, groin and any
Potent Diflorasone diacetate ointment (0.05%) and pruritic manifestations of skin area with atrophic
many inflammatory skin conditions changes or infection
- Moderate to severe forms of
psoriasis (scalp, plaque)
Highly Betamethasone dipropionate ointment (0.05%) - Relief of steroid responsive Face, axilla, groin or any
Potent Betamethasone dipropionate cream (0.05%) dermatoses skin area with infection
Betamethasone valerate ointment (0.1%) - Mild to moderate plaque psoriasis
Diflorasone diacetate cream (0.05%)
Triamcinolone acetonide ointment (0.1%)
Moderately Hydrocortisone valerate ointment (0.2%) Relief of steroid responsive Avoid prolonged use over
Potent Triamcinolone acetonide cream (0.1%) dermatoses face, groin or axilla
Betamethasone dipropionate lotion (0.02%) Avoid use in skin site with
Betamethasone valerate cream (0.1%) infection
Fluocinonide acetonide cream (0.025%)
Hydrocortisone butyrate cream (0.1%)
Hydrocortisone valerate cream (0.2%)
Low Potency Betamethasone valerate lotion (0.05%) - Relief of steroid responsive Avoid use in skin site with
Hydrocortisone acetate cream (1%) dermatoses infection
- Atopic dermatitis in children Safe to use in children
- Mild to moderate plaque psoriasis
c) Renal/electrolyte- Peripheral oedema, hypertension, long duration or under occlusive dressing in large amounts,
hypocalcaemia birth defects can result.4 It is unclear whether this preparation
2. Local/cutaneous effects is excreted in breast milk, therefore as a precaution, if topical
a) Skin atrophic changes- purpura, easy bruising, striae, application is needed over the breast, it should be applied in
telangiectasia, ulceration the longest possible interval before the next feeding, i.e.
b) Skin infection – aggravation of existing infection, immediately following a feeding session.4
secondary infection, masking of tinea incognito,
folliculitis Thus it is important for physicians to learn the correct and
c) Ocular effects- cataract, glaucoma, ocular hypertension appropriate usage of topical corticosteroids in order to
(with use of topical steroid eye drops) maximise the benefits and minimise the risks.
d) Other effects – hyper- or hypopigmentation, hirsutism,
CONCLUSION
delayed wound healing, perioral dermatitis, steroid
induced acne or rosacea
Topical corticosteroid can be either an ally or foe when
The combination of topical corticosteroid and antifungal prescribed for the treatment of a skin condition. Protocols
agents should be used cautiously in inflamed fungal skin exists for the proper use of corticosteroids taking into account
infections, as prolonged use (more than two weeks) may potency of the steroids, age of the patient, severity of the
reduce local immune response and hence aggravate the dermatoses and patient preference. Primary care physician
fungal infection.4 should empower themselves and their patients about the
indications of usage of topical corticosteroids and the
Precaution should also be exercised during pregnancy and anticipated benefits and risks.
lactation. Animal studies have shown that when used for
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